Laparoscopic Heller’s myotomy is the most common surgical procedure to treat achalasia. It is the most accepted therapy for non-advanced stages of the disease. In the setting of advanced disease with marked esophageal dilatation or sigmoid-shaped esophagus the ideal surgical procedure is debatable. Esophagectomy is believed by several authors to be the operation of choice in these cases. Others; however, opt for less invasive alternatives. Laparoscopic Heller’s myotomy has been shown to be a safe and resourceful alternative in end-stage achalasia as well.

Achalasiasurgerymyotomyend-stage diseaseIntroduction

Achalasia is a rare neurodegenerative primary esophageal motor disorder characterized by abnormal lower esophageal sphincter relaxation and aperistalsis[1]. The disease may be idiopathic[2] or secondary to Chagas’ disease - a tropical disease common in Latin America[3], although both forms have distinct etiology they share the same pathophysiology. End-stage disease with marked esophageal dilatation or sigmoid-shaped esophagus is; however, more frequent in Chagas’ disease patients [Figure 1][4].

Figure 1

Massive dilated megaesophagus in a patient with Chagas's disease esophagopathy

The degree of esophageal dilatation is used to grade the severity of the disease and may be used as a guide to tailor treatment according to some authors[5]. There is no consensus on the threshold of esophageal diameter to consider the disease as end-stage. While some adopt the limit in 6 cm[6], others prefer 7 cm[7]. In Brazil, 4 different stages of esophageal dilatation are considered[8] and end-stage disease is defined by diameterover 10 cm[9].

Laparoscopic Heller’s myotomy (LHM) is the most common surgical procedure to treat achalasia. It is the most accepted therapy for non-advanced stages of the disease[10]. In the setting of advanced disease with marked esophageal dilatation or sigmoid-shaped esophagus the ideal surgical procedure is debatable[9]. Esophagectomy is believed by several authors to be the operation of choice in these cases[11]. However, others advocate for less invasive alternatives[6].

This review discusses the role of LHM as the preferred treatment for achalasia irrespective of the degree of esophageal dilatation.

Laparoscopic Heller's myotomy role in non-advanced achalasia

LHM was described in the early 1990s[12,13] and since became a wildly accepted procedure for non-advanced achalasia[14]. Forceful pneumatic dilatation of the cardia is also a widespread primary therapy[15] but recent meta-analyses showed inferior results to dilatation as compared to LHM[10,16]. Indeed, a shift to LHM to endoscopic dilatation has occurred[17]. LHM is associated to low rates of complications, null mortality, and excellent and long-lasting outcomes superior to 90% of dysphagia relief in most series[18-20]. LHM is still the gold-standard treatment for non-advanced achalasia that must be used to compare the outcomes of other treatments such as the newly developed peroral endoscopic myotomy (POEM)[21,22].

Laparoscopic Heller's myotomy role in end-stage achalasia

Esophageal dilatation is more frequent in Chagas’ disease esophagopathy compared to idiopathic achalasia with esophageal diameter over 10 cm found from 10% to 37% of the cases[4]. This observation may explain the lack of international literature on the treatment for massive dilated esophagi. Moreover, end-stage achalasia is defined by esophageal dilatation superior to 10 cm in Brazil, thus esophagi between 6-10 cm will not be defined as advanced in the Brazilian series and will probably undergo a LHM.

Esophageal resection is the procedure historically established for end-stage achalasia in Latin America as well as globally[11,23-27]. The number of esophagectomies for the treatment of achalasia has been decreasing after the 1990s[28] in favor of less invasive methods since esophagectomy is associated with significant complications and mortality[29]. Moreover, surgical risk is directly linked to the degree of esophageal dilatation[30]. Minimally invasive techniques decreased morbidity although they are still especially considering achalasia is a benign disease[31]. Other conservative surgical techniques were tried to minimize complications, such as cardioplasty + gastrectomy (Holt and Large procedure, known in Brazil as Serra-Dória operation[32-34]), esophageal mucosectomy and endomuscular gastric tube reconstruction[35] and laparoscopic cardioplasty[36,37]. Long term results for these procedures in a significant number of patients are lacking.

Few series evaluated the results of LHM for the treatment of end-stage achalasia [Table 1]. Some advocate LHM as the primary option for advanced diseases based on the idea that an esophagectomy could be avoided. Others believe that a massive and tortuous esophagus does not empty well if only the obstacle at the esophagogastric junction is alleviated[45-47] and found worse results for LHM when the esophagus is dilated[48,49].

Table 1

Results for laparoscopic Heller's myotomy in patients with end-stage achalasia

Author

n

Follow-up (months)

Mortality (%)

Good and excellent results for dysphagia relieve (%)

Patti et al.[6] 1999

19

NR

0

91.5

Herbella et al.[38] 1999

12

40

0

97.6

Faccani et al.[39] 2007

33

89

0

69.7

Mineo and Pompeo[40] 2004

14

85

0

72

Gaissert et al.[41] 2006

12

154

0

54

Schuchert et al.[31] 2008

22

31.6

0

NR

Sweet et al.[42] 2008

12

45

0

91

Scott et al.[43] 2009

4

NR

0

100

Shuchert et al.[44] 2009

24

30.5

0

62.5

Pantanali et al.[9] 2013

11

31.5

0

72.8

Average

16

83

0

79.3

NR: not reported

There are no prospective comparative studies comparing LHM with other techniques for end-stage achalasia. Some authors show similar outcomes (complications and dysphagia control) for LHM irrespective of the degree of esophageal dilatation[9,38,42,45]. In general, excellent results may be obtained from 54-100% of the cases, with an average of almost 80% [Table 1].

LHM is not more demanding in patients with massive dilated esophagus[38]. A careful dissection of the mediastinal esophagus allows a straightening of the axis of the organ facilitating esophageal emptying[42,44].

Finally, LHM does not preclude a subsequent reoperation with a different technique. Recurrent dysphagia after LHM may be treated by endoscopic dilatation[50], POEM[50,51], redo LHM[50], cardioplasty with or without gastrectomy[33,34,36], or esophagectomy[10,50]. If a bigger operation is needed, the patient would need a better overall clinical and nutritional status.

Conclusion

LHM is a valuable therapy for advanced achalasia although data comes from retrospective case series. The procedure is associated with a low rate of complications and good/excellent results in the majority of patients. LHM is not technically more demanding and it does not preclude a subsequent reoperation with a different technique if necessary.

DeclarationsAuthors’ contributions

Acquisition of data, drafting the article, analysis and interpretation of data, final approval of the version to be published: L.M. Del Grande

Conception and design, acquisition of data, analysis and interpretation of data, drafting the article, final approval of the version to be published: F.A.M. Herbella

Analysis and interpretation of data, review for intellectual content, final approval of the version to be published: M.G. Patti

Acquisition of data, final approval of the version to be published: F. Schlottmann